NMDOH Assessment

Name*

First NameLast Name

Member ID

Birthdate*

Date

Email (for us to send your gift card)

I agree to answer these questions about my needs*

Yes

If you are pregnant, is this your first pregnancy?

YesNoN/A

When is your delivery due date? (If applicable)

Date

For you and your household, please answer if the next two statements are often true, sometimes true, or never true.

Within the past 12 months, you worried that your food would run out before you got money to buy more.*

Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more.*

Would you like help with your food needs?*

YesNoDecline to answer

Within the past 12 months, has a lack of reliable transportation kept you from medical appointments or getting medications?*

YesNoDecline to answer

Within the past 12 months, has a lack of reliable transportation kept you from doing things you need to do, such as grocery shopping or getting to work or school?*

YesNoDecline to answer

Would you like help with transportation?*

YesNoDecline to answer

What is your living situation today?*

I have a steady place to live.I have a steady place to live today, but I’m worried about losing it in the future.I don’t have a steady place to live. I am temporarily staying in another person’s home, in a hotel, shelter, car, abandoned building, bus or train station, or living outside on the street, in the woods, or in a park.Decline to answer

Do you have problems paying for utilities, such as electricity, gas, heat, air conditioning or water?*

YesNoDecline to answer

Do you have problems with utilities not working, such as electricity, gas, heat, air conditioning or water?*

YesNoDecline to answer

Do you have problems with pests like bugs or mice?*

YesNoDecline to answer

Do you have problems with mold?*

YesNoDecline to answer

Do you have problems with lead paint or pipes?*

YesNoDecline to answer

Do you have problems with smoke or carbon monoxide detectors missing or not working?*

YesNoDecline to answer

Would you like help with your living situation?*

YesNoDecline to answer

In the next 12 months, will you need help finding or paying for child care?*

YesNoDecline to answer

Would you like help with child care?*

YesNoDecline to answer

Resource Survey